A Constipation Scoring System to

Simplify Evaluation and Management

of Constipated Patients
Feran Agachan, M.D., Teng Chen, M.D., Johann Pfeifer, M.D.,
Petachia Reissman, M.D., Steven D. Wexner, M.D.,
From the Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida
PURPOSE: Constipation is a common complaint; however,
clinical presentation varies with each individual. The aim of
this study was to assess a standard scoring system for evaluation of constipated patients. MATERIALS AND METHODS: MI consecutive patients with idiopathic constipation
who were referred for anorectal physiologic testing were
assessed. A subjective constipation score was calculated
based on a detailed questionnaire that included over 100
constipation-related symptoms. Based on the questionnaire,
scores ranged from 0 to 30, with 0 indicating normal and 30
indicating severe constipation. The constipation score was
then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal
manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker
delay on CTT without evidence of paradoxical contraction
on AM, CD, or EMG. Pelvic outlet obstruction was defined
as paradoxical puborectalis contraction, rectal prolapse or
rectoanal intussusception, rectocele, or sigmoidocele. RESULTS: A total of 232 patients (185 females and 47 males) of
a mean age of 64.9 (range, 14-92) years were evaluated. All
patients had a score of more than 15; on evaluation of the
significance of different symptoms in the constipation score
with the Pearson's linear correlation test, 8 of 18 factors
were identified as significant (P < 0.05). These factors
included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time
per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical
puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal
prolapse (9). CONCLUSION: The proposed constipation
scoring system correlated well with objective physiologic
findings in constipated patients to allow uniformity in assessment of the severity of constipation. [Key words: Constipation; Colonic inertia; Sigmoidocele; Rectocele; Rectal
prolapse; Rectoanal intussusception; Anismus; Paradoxical
puborectalis contraction]
Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD. A
constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 1996;
39:681-685.

Address reprint requests to Dr. Wexner: Department of Colorectal

Surgery, Cleveland Clinic Florida, 3000 West Cypress Creek Road,
Fort Lauderdale, Florida 33309.
681

he clinical presentation of constipation includes

a b r o a d spectrum of s y m p t o m s partially attributed to the myriad etiologies. Specifically, constipation m a y result from slow transit, pelvic outlet obstruction, or other mechanical, pharmacologic,
metabolic, endocrine, and n e u r o g e n i c reasons. 1'2
Generally, physicians use the term "constipation" to
define infrequent, incomplete, difficult, or p r o l o n g e d
evacuation or to describe stools that are too small, too
hard, or too difficult to pass. 3 However, m a n y patients
are m o r e o b s e s s e d b y the associated nonspecific
s y m p t o m s of bloating, abdominal, and pelvic pain
and nausea. 4 Other difficult to categorize problems,
such as incontinence, have b e e n better described using a scoring system. 5
Therefore, the aim of this study was to establish an
objective constipation scoring system b a s e d o n patients' complaints. Specific attention w a s paid to b o t h
subjective symptomatic complaints a n d physiologic
findings.

MATERIALS AND METHODS

A consecutive series o f 232 constipated patients
w e r e enrolled in this study. Patients w e r e interviewed
b y a nurse or a resident regarding their b o w e l habits.
The standardized questionnaire c o n c e r n e d 12 addressed items, including constipation duration and
severity, b o w e l habits, stool consistency, intake of
fiber, f r e q u e n c y and a m o u n t s of laxatives, suppositories, digitation or enemas, duration and f r e q u e n c y o f
assistance, length of straining time per attempt, unsuccessful attempts for evacuation per 24 hours, sensation o f incomplete evacuation, m u c u s discharge,
rectal bleeding, sensation of prolapse, incontinence,
psychologic, endocrinologic, metabolic, or neurologic history, previous abdominal, gynecologic, or
colorectal surgery, pelvic irradiation, regular use of
medication, pregnancy, a n d vaginal deliveries.
All patients u n d e r w e n t extensive anorectal exami-

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AGACHAN ET AL

nation, including inspection, digital examination,

anoscopy, and proctosigmoidoscopy before treatment. In addition, patients underwent anal and colorectal physiologic studies including colonic transit
time, cinedefecography (CD), anal manometry, and
electromyography (EMG). These studies were performed as previously described. 1' 6, r When indicated,
all patients underwent a comprehensive evaluation
such as barium enema, colonoscopy, biochemical
and metabolic profile, small bowel transit, or psychiatric consultation to exclude organic causes of constipation.

Definitions
Colonic inertia has been defined as the presence of
at least 80 percent of transit markers scattered diffusely throughout the colon on the fifth day after
ingestion. 8 Patients with paradoxical puborectalis
contraction, rectoanal intussusception, sigmoidocele,
rectocele, or rectal prolapse were classified as having
pelvic outlet obstruction. 9-13 Paradoxical puborectalis
contraction was defined by the finding of at least two
of the three following abnormalities: retention of at
least 20 percent of the colonic markers in the rectum
on the fifth day of the colonic transit time study,
inability to achieve rapid and complete evacuation of
200 ml (500 g) of barium paste on CD with lack of a
measurable increase in the anorectal angle between
radiographic views taken at rest and during attempted
evacuation, and a paradoxical increase in puborectalis neuromuscular activity during EMG. Rectoanal
intussusception was defined as a circumferential infolding of more than 4 mm of rectal mucosa. 14 Sigmoidocele was defined as a deep rectovaginal fossa
with an elongated loop of sigmoid extending caudally. 15 It was diagnosed and classified based on the
degree of descent of the lowest portion of the sigmoid
on CD. Rectocele is a herniation of the anterior rectal
and posterior vaginal walls into the lumen of the
vagina. A rectocele was defined as any herniation of 3
cm or more in diameter occurring during defecation
or straining. Rectal prolapse was defined as procidentia of the full thickness of the rectum through the anal
canal. Sigmoidocele, rectocele, intussusception, and
prolapse were all diagnosed by CD.

Constipation Scoring System

The constipation scoring system was derived based
on answers to the questions in the symptom questionnaire.

Dis Colon Rectum, June 1996

Statistical Analysis
Pearson's correlation coefficient analysis was used
to compare quantified values and the unpaired t-test
w h e n qualitative data were required. Association of
qualitative values were verified by chi-squared analysis with Yates' correction, w h e n possible. Statistical
significance was P < 0.05.
RESULTS
A total of 232 patients (185 w o m e n and 47 men)
with a mean age of 64.9 (range, 14-92) years was
assessed. All patients had a diagnosis of constipation,
with a mean duration of 16.8 years (range, 3
months-72 years). Colonic transit time, anal manometry, EMG, or CD confirmed the presence of constipation in all patients. Sixty-eight of these 232 patients
had colonic inertia, and 164 had pelvic outlet obstruction attributable to one or more of the following:
paradoxical puborectalis contraction (81), rectoanal
intussusception (64), sigmoidocele (36), rectocele
(48), and rectal prolapse (9).
Based on statistical analysis, eight variables were
selected for the scoring system. These items include
frequency of bowel movements, painful evacuation,
incomplete evacuation, abdominal pain, length of
time per attempt, assistance for defecation, unsuccessful attempts for evacuation per 24 hours, and
duration of constipation (Table 1). A scoring range of
0 to 4 (with the exception of "assistance for defecation," which is 0-2) was derived. The global score was
obtained by adding each individual score. A score of
more than 15 was the definition of the symptom
"constipation" in this study. Patients with etiologies
based on mechanical, pharmacologic, metabolic, endocrine, or neurogenic reasons were excluded.
Pearson's linear correlation test estimated the severity of constipation using these eight parameters; however, these parameters can be biased by the study
groups' criteria and characteristics. To prevent this
error, a validation sample was established. Before
evaluating all cases, pilot groups of 50 constipated
and 50 nonconstipated patients confirmed by physiologic studies were randomly selected. This study
correctly predicted the actual results (Table 2). This
pilot group validated the accuracy of the constipation
scoring system, and subsequently, the entire study
group was assessed. Using the Pearson's linear correlation test, eight of the generated factors had a significance level of P < 0.05; 97 percent of the entire
group had a score greater than 15.

Vol. 39, No. 6

CONSTIPATION SCORING SYSTEM

Table 1.

Constipation Scoring System (Minimum Score, 0;

Maximum Score, 30)
Frequency of bowel movements
1-2 times per 1-2 days
2 times per week
Once per week
Less than once per week
Less than once per month
Difficulty: painful evacuation effort
Never
Rarely
Sometimes
Usually
Always
Completeness: feeling incomplete
evacuation
Never
Rarely
Sometimes
Usually
Always
Pain: abdominal pain
Never
Rarely
Sometimes
Usually
Always
Time: minutes in lavatory per attempt
Less than 5
5-10
10-20

20 -30
More than 30
Assistance: type of assistance
Without assistance
Stimulative laxatives
Digital assistance or enema
Failure: unsuccessful attempts for
evacuation per 24 hours
Never
1-3
3-6
6-9
More than 9
History: duration of constipation (yr)
0
1-5
5-10
10-20
More than 20

Score
0
1
2
3
4
0
1
2
3
4

0
1
2
3
4
0
1
2
3
4
0
1
2

3
4
0
1
2

0
1
2
3
4
0
1
2
3
4

After establishing the constipation scoring system,

two control groups were created. Group I consisted of
30 patients who were not constipated as confirmed by
physiologic studies. Group II consisted of 30 controls
who did not undergo any physiologic studies. All

683

samples in both groups had scores under 8, with a

mean score of 2.1 in Group I and 3.4 in Group II.

DISCUSSION
Constipation is a common clinical complaint but a
poorly defined clinical constellation. It is difficult to
describe normal bowel function but most people
evacuate between three times per day and once every
three days) Marginal infrequency beyond this may be
attributed to poor diet and frequently responds to
bulk laxatives. Recent demographic studies have
shown that 2 percent of the population in the United
States is affected by constipation. 3 If conventional
investigations do not reveal any causative abnormalit-y, constipation is considered to be functional, which
makes application of functional tests that assess anal
and anorectal function mandatory for further evaluation.16, 17
Several prior attempts have been made to study
constipation. Drossman and coworkers 18 surveyed
789 students and hospital employees and found that
17.5 percent strained at stool more than 25 percent of
the time. Moreover, 4.2 percent reported two or fewer
bowel movements per week. These figures were
slightly higher than Thompson and Heaton ~9reported
in an earlier survey. Although the survey by Drossman
and colleagues ~s queried abdominal pain, distention,
and incomplete evacuation, it did so in the context of
diagnosis of irritable bowel syndrome rather than
constipation. Much data have been published regarding psychological abnormalities in patients with constipation. 2~ One prior publication included a comparison of symptoms and type of constipation. 24
In 1991, Pemberton e t al. 25 clearly demonstrated
the importance in differentiating between slow transit
constipation and pelvic floor dysfunctions. Specifically, they found that 10 percent of a group of 277
thoroughly investigated, constipated patients had
slow transit constipation; 13 percent had pelvic floor
dysfunction, and 5 percent had both. The overwhelming majority of patients (70 percent) had irritable
bowel syndrome. Thus, although the success rate of
surgery for constipation was high in that series, the
authors cautioned against performing such surgery in
patients with irritable bowel syndrome.
Subsequently, that same group sought to classify
184 patients into one of the aforementioned groups
based on psychological distress and colorectal symptoms. 24 After a thorough evaluation, the authors were
unable to assign significance to correlation between

684

AGACHAN E T AL

Table 2.
Validation Sample (100 Cases)
Predicted Unpredicted
Constipation Constipation
Confirmed constipation
49
1
Unconfirmed constipation
3
47
A total of 96% of cases were correctly predicted (P <
0.05).

s y m p t o m s and type of constipation. Significant correlation included normal transit constipation with increased depression scores, general severity index
with total colonic transit, and a feeling of anal blockage with pelvic floor dysfunction.
This study demonstrates the use of a constipation
scoring system in assessing patients with constipation.
It also confirms the unreliability of some of the parameters w h e n they are used alone to define constipation. For example, stool frequency is modulated by
the voluntary and subjective c o m p o n e n t s of defecation and does not correlate with transit times, also
taking into account stool weight and thus reflects
better stool output.
The patients in this study s h o w e d two different
profiles. Patients in the colonic inertia group were
predominantly females, with a chronic history of constipation unresponsive to n u m e r o u s treatment regimens. They reported abdominal distention and discomfort b e t w e e n infrequent evacuations. They were
unable to have spontaneous evacuations and generally experienced better results with laxatives than
with enemas, suppositories, or digitation.
In the pelvic outlet group, a combination of findings was observed, including a history of difficult and
incomplete evacuation, which often requiring digitation. This group of patients was unable to have spontaneous b o w e l evacuations and generally experienced better results with enemas, suppositories, and
digitation than with laxatives.
In our series of 232 patients, we defined eight
parameters that were significant in predicting constipation, as described earlier in this study report. After
identifying the significant parameters and establishing
the scoring system, patients w e r e scored. As scores
increased, a corresponding significant increase in severity of constipation was noted, thus validating the
applicability of this constipation scoring system. Thus,
the current study had a different design than either of
the two previous symptom-related surveys. 18' 24

Dis Colon Rectum, June 1996

CONCLUSION

D e v e l o p m e n t of a constipation scoring system was

derived to obtain a universally objective definition of
"constipation" to assist in the diagnosis and treatment
of constipated patients. Initial clinical validation
proved this scoring system to be accurate. Further
prospective evaluation is warranted to ascertain impact on therapeutic decision-making.

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